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A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients



Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus.


A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice.


The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultra-high-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions.


These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying AVF stenoses and provide unified evidence-based practice guidelines.

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  1. 1.

    Gala S, Mathur I, Osman N, Erdal E, Ramachandran R, Dawson D. Clinical and economic outcomes associated with treatment of hemodialysis arteriovenous fistula or graft stenosis. In: 11th Congress of the Vascular Access Society. Rotterdam, the Netherlands; 2019. Available from

  2. 2.

    Gala S, Mathur I, Osman N, Erdal E, Ramachandran R, Dawson D. Economic burden and healthcare resource utilization associated with hemodialysis arteriovenous accesses. In: 11th Congress of the Vascular Access Society. Rotterdam, the Netherlands; 2019. Available from

  3. 3.

    Schmidli J, Widmer MK, Basile C, et al. Editor’s choice: vascular access: 2018 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(6):757–818.

    Article  Google Scholar 

  4. 4.

    Dariushnia SR, Walker TG, Silberzweig JE, et al. Quality improvement guidelines for percutaneous image-guided management of the thrombosed or dysfunctional dialysis circuit. J Vasc Interv Radiol. 2016;27(10):1518–30.

    Article  Google Scholar 

  5. 5.

    Trerotola SO, Lawson J, Roy-Chaudhury P, Saad TF. Drug coated balloon angioplasty in failing av fistulas: a randomized controlled trial. Clin J Am Soc Nephrol. 2018;13(8):1215–24.

    CAS  Article  Google Scholar 

  6. 6.

    Rajan DK, Sidhu A, Noel-Lamy M, et al. Elastic recoil after balloon angioplasty in hemodialysis accesses: does it actually occur and is it clinically relevant? Radiology. 2016;279(3):961–7.

    Article  Google Scholar 

  7. 7.

    Sachdeva B, Abreo K. Drug-coated balloon angioplasty for hemodialysis fistula maintenance. Clin J Am Soc Nephrol. 2018;13(8):1140–1.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Trerotola SO, Kwak A, Clark TWI, et al. Prospective study of balloon inflation pressures and other technical aspects of hemodialysis access angioplasty. J Vasc Interv Radiol. 2005;16(12):1613–8.

    Article  Google Scholar 

  9. 9.

    Kitrou PM, Spiliopoulos S, Katsanos K, Papachristou E, Siablis D, Karnabatidis D. Paclitaxel-coated versus plain balloon angioplasty for dysfunctional arteriovenous fistulae: one-year results of a prospective randomized controlled trial. J Vasc Interv Radiol. 2015;26(3):348–54.

    Article  Google Scholar 

  10. 10.

    Massmann A, Fries P, Obst-Gleditsch K, Minko P, Shayesteh-Kheslat R, Buecker A. Paclitaxel-coated balloon angioplasty for symptomatic central vein restenosis in patients with hemodialysis fistulas. J Endovasc Ther. 2015;22(1):74–9.

    Article  Google Scholar 

  11. 11.

    Kitrou PM, Spiliopoulos S, Papadimatos P, et al. Paclitaxel-coated balloons for the treatment of dysfunctional dialysis access. Results from a single-center, retrospective analysis. Cardiovasc Intervent Radiol. 2017;40(1):50–4.

    Article  Google Scholar 

  12. 12.

    Kitrou P, Spiliopoulos S, Karnabatidis D, Katsanos K. Cutting balloons, covered stents and paclitaxel-coated balloons for the treatment of dysfunctional dialysis access. Expert Rev Med Devices. 2016;13(12):1119–26.

    CAS  Article  Google Scholar 

  13. 13.

    Agarwal SK, Nadkarni GN, Yacoub R, et al. Comparison of cutting balloon angioplasty and percutaneous balloon angioplasty of arteriovenous fistula stenosis: a meta-analysis and systematic review of randomized clinical trials. J Interv Cardiol. 2015;28(3):288–95.

    Article  Google Scholar 

  14. 14.

    Saleh HM, Gabr AK, Tawfik MM, Abouellail H. Prospective, randomized study of cutting balloon angioplasty versus conventional balloon angioplasty for the treatment of hemodialysis access stenoses. J Vasc Surg. 2014;60(3):735–40.

    Article  Google Scholar 

  15. 15.

    Bountouris I, Kritixkou G, Degermetzoglou N, Avgerinos KI. A review of percutaneous transluminal angioplasty in hemodialysis fistula. Int J Vasc Med. 2018;2018:1420136.

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Aftab SA, Tay KH, Irani FG, et al. Randomized clinical trial of cutting balloon angioplasty versus high-pressure balloon angioplasty in hemodialysis arteriovenous fistula stenoses resistant to conventional balloon angioplasty. J Vasc Interv Radiol. 2014;25(2):190–8.

    Article  Google Scholar 

  17. 17.

    Shemesh D, Goldin I, Olsha O. Stent grafts for treatment of cannulation zone stenosis and arteriovenous graft venous anastomosis. J Vasc Access. 2017;18(Suppl. 1):47–52.

    Article  Google Scholar 

  18. 18.

    Fu N, Joachim E, Yevzlin AS, Shin J-I, Astor BC, Chan MR. A meta-analysis of stent placement vs. angioplasty for dialysis vascular access stenosis. Semin Dial. 2015;28(3):311–7.

    Article  Google Scholar 

  19. 19.

    Abreo K, Sequeira A. Role of stents in hemodialysis vascular access. J Vasc Access. 2018;19(4):341–5.

    Article  Google Scholar 

  20. 20.

    Shemesh D, Goldin I, Zaghal I, Berlowitz D, Raveh D, Olsha O. Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial. J Vasc Surg. 2008;48(6):1524–31.

    Article  Google Scholar 

  21. 21.

    Katzman HE, McLafferty RB, Ross JR, Glickman MH, Peden EK, Lawson JH. Initial experience and outcome of a new hemodialysis access device for catheter-dependent patients. J Vasc Surg. 2009;50(3):600-607.e1.

    Article  Google Scholar 

  22. 22.

    Boitet A, Massy ZA, Goeau-Brissonniere O, Javerliat I, Coggia M, Coscas R. Drug-coated balloon angioplasty for dialysis access fistula stenosis. Semin Vasc Surg. 2016;29(4):178–85.

    Article  Google Scholar 

  23. 23.

    Falk A, Maya ID, Yevzlin AS. A prospective, randomized study of an expanded polytetrafluoroethylene stent graft versus balloon angioplasty for in-stent restenosis in arteriovenous grafts and fistulae: two-year results of the RESCUE study. J Vasc Interv Radiol. 2016;27(10):1465–76.

    Article  Google Scholar 

  24. 24.

    Vesely T, DaVanzo W, Behrend T, Dwyer A, Aruny J. Balloon angioplasty versus Viabahn stent graft for treatment of failing or thrombosed prosthetic hemodialysis grafts. J Vasc Surg. 2016;64(5):1400-1410.e1.

    Article  Google Scholar 

  25. 25.

    Argyriou C, Schoretsanitis N, Georgakarakos EI, Georgiadis GS, Lazarides MK. Preemptive open surgical vs. endovascular repair for juxta-anastomotic stenoses of autogenous AV fistulae: a meta-analysis. J Vasc Access. 2015;16(6):454–8.

    Article  Google Scholar 

  26. 26.

    Napoli M, Prudenzano R, Russo F, Antonaci AL, Aprile M, Buongiorno E. Juxta-anastomotic stenosis of native arteriovenous fistulas: surgical treatment versus percutaneous transluminal angioplasty. J Vasc Access. 2010;11(4):346–51.

    Article  Google Scholar 

  27. 27.

    Maleux G, Vander Mijnsbrugge W, Henroteaux D, et al. Multicenter, randomized trial of conventional balloon angioplasty versus paclitaxel-coated balloon angioplasty for the treatment of dysfunctioning autologous dialysis fistulae. J Vasc Interv Radiol. 2018;29(4):470-475.e3.

    Article  Google Scholar 

  28. 28.

    Katsanos K, Karnabatidis D, Kitrou P, Spiliopoulos S, Christeas N, Siablis D. Paclitaxel-coated balloon angioplasty vs. plain balloon dilation for the treatment of failing dialysis access: 6-month interim results from a prospective randomized controlled trial. J Endovasc Ther. 2012;19(2):263–72.

    Article  Google Scholar 

  29. 29.

    Kitrou PM, Papadimatos P, Spiliopoulos S, et al. Paclitaxel-coated balloons for the treatment of symptomatic central venous stenosis in dialysis access: results from a randomized controlled trial. J Vasc Interv Radiol. 2017;28(6):811–7.

    Article  Google Scholar 

  30. 30.

    Kitrou PM, Katsanos K, Spiliopoulos S, Karnabatidis D, Siablis D. Drug-eluting versus plain balloon angioplasty for the treatment of failing dialysis access: final results and cost-effectiveness analysis from a prospective randomized controlled trial (NCT01174472). Eur J Radiol. 2015;84(3):418–23.

    Article  Google Scholar 

  31. 31.

    Irani FG, Teo TKB, Tay KH, et al. Hemodialysis arteriovenous fistula and graft stenoses: randomized trial comparing drug-eluting balloon angioplasty with conventional angioplasty. Radiology. 2018;289(1):238–47.

    Article  Google Scholar 

  32. 32.

    Lucev J, Breznik S, Dinevski D, Ekart R, Rupreht M. Endovascular treatment of haemodialysis arteriovenous fistula with drug-coated balloon angioplasty: a single-centre study. Cardiovasc Intervent Radiol. 2018;41(6):882–9.

    Article  Google Scholar 

  33. 33.

    Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M, Karnabatidis D. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2018;7(24):e011245.

    Article  Google Scholar 

  34. 34.

    Dinh K, Limmer AM, Paravastu SCV, et al. Mortality after paclitaxel-coated device use in dialysis access: a systematic review and meta-analysis. J Endovasc Ther. 2019;26(5):600–12.

    Article  Google Scholar 

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The authors would like to acknowledge the support of K McKillen in facilitating the Delphi meeting and K McKillen and Prescript Communications in preparing the manuscript.


This study was funded by Bard Limited. All authors received participant’s honoraria from Bard Limited to attend the meeting; however, the views and opinions reported are those of the authors only and were not influenced by Bard Limited. Bard Limited is now a wholly owned subsidiary of BD (Becton Dickinson & Company).

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Correspondence to Ounali Jaffer.

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Jaffer, O., Gibbs, P., Gibson, M. et al. A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients. Cardiovasc Intervent Radiol 44, 1736–1746 (2021).

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  • Stenoses
  • Arteriovenous fistula
  • Fistuloplasty angiography
  • Dialysis access intervention
  • Haemodialysis